Colorectal cancer

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Treatments for stage 4 or recurrent colon cancer

Treatment options are often the same for both stage 4 and recurrent colon cancer because the cancer is in other organs. Stage 4 means that the cancer has spread to one or more other organs. If colon cancer recurs, it usually comes back in a distant site such as the liver.

The following are treatment options for stage 4 or recurrent colon cancer. Treatment options and the order they are used depend on if the cancer is resectable (it can be removed with surgery) or unresectable (it can’t be removed with surgery). Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.


Chemotherapy is usually offered for stage 4 or recurrent colon cancer. It may be used as the primary treatment for unresectable tumours in the colon or metastases in the liver. It may also be given before surgery (called neoadjuvant chemotherapy) to shrink tumours to make the cancer resectable or the surgery easier. If the cancer is resectable, chemotherapy is usually given after surgery (called adjuvant chemotherapy) to kill any cancer cells that may be left behind and prevent the cancer from coming back.

How long chemotherapy is given depends on the type of chemotherapy used, the cancer’s response to the drug or drug combination and if surgery is done. For resectable colon cancer, chemotherapy is usually given for 6 months. For unresectable colon cancer, chemotherapy may be used as long as the cancer responds or until the disease progresses.

When deciding on which chemotherapy drug or drug combination to offer, your doctors will consider your overall health and the possible side effects. The chemotherapy drugs used for stage 4 or recurrent colon cancer include:

  • FOLFIRI – leucovorin (folinic acid), 5-fluorouracil (Adrucil, 5-FU) and irinotecan (Camptosar)
  • FOLFOX – leucovorin (folinic acid), 5-fluorouracil (Adrucil, 5-FU) and oxaliplatin (Eloxatin)
  • CAPOX (also called XELOX) – capecitabine (Xeloda) and oxaliplatin (Eloxatin)
  • CAPIRI – capecitabine (Xeloda) and irinotecan (Camptosar)
  • capecitabine (Xeloda)
  • irinotecan (Camptosar)
  • 5-fluorouracil (Adrucil, 5-FU) with leucovorin (folinic acid)
  • raltitrexed (Tomudex)
  • trifluridine plus tipiracil hydrochloride (Lonsurf)

FOLFIRI is used most often for stage 4 or recurrent colon cancer. It is also the standard first-line chemotherapy used for metastatic colorectal cancer. You may be given other chemotherapy combinations or single drugs if FOLFIRI can’t be used, if FOLFIRI causes a lot or severe side effects or if the cancer progresses.

Hepatic arterial infusion may be used to treat liver metastases when cancer has only spread to the liver and it can’t be removed with surgery. It delivers chemotherapy directly to liver tumours through the main artery of the liver (called the hepatic artery). Floxuridine (FUDR) is the most common chemotherapy drug used for hepatic arterial infusion. Hepatic arterial infusion is not used very often because it has to be done in a hospital by a large healthcare team who are trained to give this treatment.

Targeted therapy

Targeted therapy is usually offered for stage 4 or recurrent colon cancer. It is usually given with chemotherapy, but it may be used alone in some cases.

The targeted therapy drugs used depend on if chemotherapy is also given and if the colon cancer cells have the KRAS gene mutation. If the colon cancer cells don’t have the KRAS gene mutation, the tumours are called KRAS wild-type tumours. Targeted therapy drugs used for stage 4 or recurrent colon cancer include:

  • bevacizumab (Avastin), which is usually given with FOLFIRI or FOLFOX
  • cetuximab (Erbitux), which can be given with irinotecan (Camptosar) or alone for KRAS wild-type tumours
  • panitumumab (Vectibix), which is usually used alone for KRAS wild-type tumours
  • regorafenib (Stivarga), which is given if the cancer progresses after most other treatments

Bevacizumab with FOLFIRI is used most often for stage 4 or recurrent colon cancer. It is also the standard treatment for metastatic colorectal cancer.

Doctors may not give targeted therapy drugs before surgery if they think that all of the tumour can be removed so that there are no cancer cells in the healthy tissue removed along with the tumour (called negative surgical margins). They may give targeted therapy after surgery.


You may be offered surgery for stage 4 or recurrent colon cancer. Whether or not surgery is an option will depend on the location of the tumour, the stage of the cancer and your overall health.

Surgery to remove metastatic tumours is done when the cancer has spread to only one distant organ (such as the liver or lung). The type of surgery done will depend on where the cancer has spread.

Bowel resection is done to remove cancer in the colon. It may also be used to treat a blockage in the intestine (called bowel obstruction). Depending on the location of the tumour or blockage, the surgeon may do a right hemicolectomy, transverse colectomy, left hemicolectomy, sigmoid colectomy, subtotal colectomy or total colectomy.

Colostomy may be done to allow the intestine to rest and heal after a bowel resection. This surgery creates a stoma (artificial opening) from the colon to the outside of the body through the abdominal wall. The colostomy is usually temporary. The 2 ends of the colon are joined together after they have healed.

Diverting colostomy is a colostomy that doesn’t remove part of the intestine. It may used to treat bowel obstruction by creating a passage so stool can leave the body before it reaches the blocked part of the intestine.

Stent placement may be done to treat or prevent bowel obstruction. The doctor can place a metal mesh-like tube (called a stent) in the intestine to open it so stool can flow normally. Stents are often used to relieve symptoms of advanced cancer (called palliative therapy).

Radiofrequency ablation (RFA) may be used to treat liver metastases that can’t be removed with surgery. RFA uses a high-frequency electrical current to destroy cancer cells. It is done with a special probe or needle inserted into the tumours in the liver. In most cases, the doctor gives the RFA through the skin and into the tumour. In other cases, the doctor may need to make a cut, or incision, in the abdomen to reach the liver. Sometimes the doctor will only make small cuts in the abdomen and use a laparoscope to give the RFA.

Radiation therapy

You may be offered radiation for stage 4 or recurrent colon cancer. Most often it is used as palliative therapy to control symptoms such as pain. External beam radiation therapy to the abdomen or pelvis may be used for unresectable colon cancer. It may also be used to treat bone or brain metastases.

Clinical trials

You may be asked if you want to join a clinical trial for colon cancer. Find out more about clinical trials.


Giving relief.

For example, palliative therapies relieve symptoms but do not cure disease.


A procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis.

Cells or tissue may be removed for examination under a microscope. Doctors may also use laparoscopy to perform different surgical procedures in the abdomen and pelvis.

The type of endoscope used for this procedure is called a laparoscope.


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